- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.04 / $912.89 / $1,096.99
| Professional | | $633.04 | $912.89 | $1,096.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.72 / $1,008.72 / $1,068.06
| Professional | | $1,008.72 | $1,008.72 | $1,068.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.95 / $1,074.65 / $1,404.78
| Professional | | $422.95 | $1,074.65 | $1,404.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.03 / $934.32 / $1,374.00
| Professional | | $437.03 | $934.32 | $1,374.00 |